Workers Compensation Guide For Employees

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Workers’

Compensation

Guide

For

Employees

Risk Management, SA 4701

25800 Carlos Bee Blvd. , Hayward, CA 94542

(510) 885-4227 FAX (510) 885-4908

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Introduction

Cal State East Bay is committed to providing a safe working environment for you. However, in the event you experience an injury or illness resulting from employment, you may be entitled to

Workers' Compensation benefits. Such an injury or illness may have resulted from a single incident or from repeated and prolonged exposure to activities or substances at work.

It is the responsibility of Risk Management to minimize the impact on you in the event an injury occurs. It is also our goal to facilitate your return to full employment as soon as possible. To achieve this goal, we will:

 Ensure you receive immediate medical attention;

 Coordinate payment of disability benefits in a timely manner, if applicable;

 Assist you in returning to modified or transitional duty, if applicable; and

 Assist you in understanding the Workers’ Compensation process, answer questions and provide pertinent information regarding your claim.

Forms located in the appendix can be downloaded through the Risk Management website:

www.aba.csueastbay.edu/hr

Frequently Used Telephone Numbers

 Emergency Dial 9-1-1 (Campus Police will dispatch Ambulance – Fire Department)  Risk Management

o Workers’ Compensation Coordinator (510) 885-4227 o Fax (510) 885-4908

 Student Health Center (510) 885-3736 First Aid Only (one visit)  Sedgwick Claims Management Services (916) 851-8000

P.O. Box 14629

Lexington, KY 40512-4629

Sedgwick CMS administers California State University, East Bay’s Workers’ Compensation program. Sedgwick CMS is a claims management firm headquartered in Sacremento California. They

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What is Workers’ Compensation?

Workers’ Compensation is an employer-paid benefit program that provides compensation and medical benefits if an employee is injured or becomes ill due to a work related

circumstance.

Any injury or illness is covered under Workers’ Compensation if it is caused by the employee’s job. This includes serious injuries as well as first aid injuries. Under

Workers’ Compensation law, the employee may receive medical care if he/she is injured, no matter who was at fault. Eligibility for benefits will be determined by CSU’s third party Workers’ Compensation claims administrator, Sedgwick Claims Management Services

Some injuries may not be covered through the Workers’ Compensation program. Such cases may include but are not limited to injuries while voluntarily engaging in recreational, social, or athletic activities outside of the employee’s work duties.

Who is covered?

California State University, East Bay employees which includes faculty, staff, special consultants, student assistants, and work study students, and appointed volunteers are covered by Workers’ Compensation. Volunteers include non-paid board members, non-paid faculty, student teachers or any other person

registered with the school, who is volunteering their time to benefit the University. If a volunteer sustains an injury/illness/disease, the department must follow the Workers’ Compensation reporting procedures.

Employees under contract must refer to their agreement with the University in order to determine who covers Workers’ Compensation benefits.

Injuries and Illnesses

According to the California Labor Code, the term "injury" includes any injury, illness, or disease arising out

of employment and occurring in the course of employment (AOE/COE). Other terms used in reference to

an injury are: industrial injury, industrial accident, compensable injury, and work injury. Injuries are categorized in three ways:

 Specific: Injury to one or more parts of the body resulting from a specific incident. (Example- Employee falls down stairs and fractures a bone.)

 Cumulative: Injury from repetitive traumatic activities over a period of time. (Example- Employee experiences hearing loss due to repeated noise exposure.)

 Aggravation: A pre-existing condition or non work-related condition aggravated by an occupational injury or disease. The employer provides medical treatment until the employee returns to the pre-injury status of the pre-existing condition.

(Example- Employee’s previous back injury exacerbated by continued heavy lifting.) Sedgwick will evaluate reported injuries/illness based on:

 The accident/exposure must have occurred during assigned work hours. (Assigned work hours begin when the employee arrives at work.) Workers’ Compensation benefits generally do not cover accidents that occur while coming and going to work or at lunch, unless the lunch period is “paid time” and attendance on University property is required.

 The accident/exposure must have occurred on the employer’s premises or a location required by the employer.

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 The accident/exposure must have occurred while performing a work-related activity. A work-related activity is defined as one that benefits the employer, even if it may not be an assigned duty. For this reason, injuries/exposures that occur on authorized breaks are generally covered by Workers’ Compensation.

A claim may be denied or reduced in benefits if injury or illness was due to:

 The employee was intoxicated or had illegal drugs in his or her system at the time the injury occurred.

 Self-inflicted injuries are not covered under Workers’ Compensation.

 Injuries/Illnesses caused by an accident/exposure, which is defined as an unexpected and unforeseen event (i.e., acts of nature—lightening, earthquakes…)

 Injuries sustained by an employee who assaults or was involved in activities intended to injure another person are not covered. However, the innocent injured employee would be covered by Worker’s Compensation and Sedgwick CMS, our third party administrator, may act against the assaulting employee to recover monetary damages.

 If it is determined by the insurer that the employee misrepresented his/her claim  The employee knowingly works outside his/her limitations while on modified duty Pre-Designating Your Treating Physician

You have the option of pre-designating your personal physician as your treating physician in the event of a work-related injury/illness. This must be done in advance. If you choose to pre-designate, we suggest checking with your personal physician to be certain they will treat work-related injuries/illnesses as a signature is required by your physician on the pre-designation form. It is also your responsibility to update your designation should you change physicians. The Workers' Compensation Personal Physician

Designation Form is available through the Risk Management website under Workers’ Compensation

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What must I do if I become injured or ill on the job?

 Report the injury/illness to your Manager/Supervisor

The employee must report any injury or illness to their manager/supervisor within 8 (eight) hours, no matter how trivial the injury may seem. The employee will need to provide where the injury/illness occurred, what happened, and if anyone witnessed the injury. This information will assist the manager/supervisor in completing the

Supervisor's Report of Employee Injury/Illness. Prompt reporting of an injury/illness

will help prevent problems and delays in receiving benefits, including medical care the employee may need to avoid further injury.

Risk Management may need to provide the employee with an Authorization for Treatment form based on the injury/illness incurred. The employee will also need to complete the Employee’s Injury/Illness

Report.

 Obtain medical treatment

If the injury/illness requires emergency assistance:

 Call 911 immediately from any campus phone. This number will then connect you to the University’s police dispatcher, who will send a police officer and if needed emergency medical personnel to assist the injured employee. These injuries/illness include but are not limited to:

 Excessive bleeding and broken bones  Chest pain

 Unconsciousness  Life threatening injuries

 First Aid: If the injury or illness requires medical attention and it is not an emergency, the

supervisor will direct the employee to Student Health Services. This medical facility is designated to treat FIRST AID injuries and/or injury/illnesses that require no more than one visit. When the employee goes to Student Health Services for evaluation and/or treatment, Risk Management will provide the employee with an Authorization for Treatment form to take with him/her. These injuries/illness include but are not limited to:

 Minor injuries and illnesses  Cuts, scratches, scrapes

 Injuries/Illness: If the injured employee requires treatment beyond First Aid, Risk Management will refer the employee to a designated occupational medical facility unless there is a Pre-designation of Treating Physician form on file in Risk Management. These injuries/illness include but are not limited to:

 Back injuries, knee strains

 Exposure to hazardous substances  Cumulative trauma injuries

For any injuries/illnesses occurring on weekends or after work hours, you will be directed to St. Rose Emergency Medical Center or the nearest emergency room.

Claims filed under Workers’ Compensation will be reported to our third party administrator, Sedgwick Claims Management Services P.O. Box 14629 Lexington, KY 40512-4629 Telephone: (916) 851-8000. Sedgwick will make the final determination of whether the injury/illness is work related and what benefits the injured employee is entitled to receive.

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Employee’s Responsibility

 It is your responsibility to inform Risk Management and your supervisor how long your doctor expects you to be away from work. A good rule of thumb is to call after your doctor’s appointments to give him/her an update on your medical progress.

 If you are scheduled for surgery or a medical procedure that will require a day or more of time off due to your Workers’ Compensation injury/illness, a physician’s note will need to be provided to Risk Management prior to your scheduled surgery/medical procedure. An appointment will be

scheduled with the Workers’ Compensation Coordinator in Risk Management to review your eligibility for benefits and compensation.

 When your doctor permits you to return to work:

1. Give Risk Management and your supervisor as much notice as possible to help in scheduling work.

2. If you have work restrictions from your doctor, Risk Management needs a written doctor’s statement before you return to work. Restrictions will be discussed with your supervisor. 3. Your doctor’s statement will allow your department to determine whether they can find job

tasks that fit your physical needs. Your department may be able to provide transitional work for you.

4. Until you are returned to full duty without restrictions, work restrictions and follow-up appointment dates need to be provided to Risk Management within 24 hours of your appointment.

5. You are personally responsible for working within the limits of your physician’s work restrictions. If you are unable to perform the tasks assigned, you must contact your supervisor/manager and the Workers’ Compensation Coordinator immediately.

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What to Expect When You File a Workers’ Compensation Claim

Risk Management will provide the employee with a Workers’ Compensation Packet containing: o Workers’ Compensation Claim Form(DWC-1)

o Employee’s Injury/Illness Report o Employee’s Responsibility

o Medical Releases

o Workers’ Compensation Facts o Workers’ Compensation Q & A

 Employee completes the Workers’ Compensation Claim Form (DWC-1) and Employee’s Report of Work

Injury/Illness and returns them to Risk Management.

 Employee is eligible for medical treatment. Risk Management will determine if an Authorization for

Treatment form is necessary. The Authorization for Treatment does not constitute an acceptance or denial

of the claim. If prior to the injury, the employee filed a Physician Pre-designation form in Risk Management, he/she may choose not to be seen by the University’s designated physician network.

 Employee will receive a telephone call from Sedgwick CMS, CSU East Bay workers’ compensation carrier, to address the facts on the claim.

 Sedgwick CMS will then mail a packet of information to the employee requesting authorization for medical releases for past medical history. Employee will also be provided with a Mileage Reimbursement form. In addition, Sedgwick CMS may assign a representative to interview the employee, supervisor, and any witnesses concerning the claim.

 If deemed necessary, the employee will be provided information pertaining to a Qualified Medical Evaluator (QME) in order to determine if the illness is industrially related (arises out of or in the course of employment). Prior to the exam, the physician will receive past medical records and any information that could be helpful in the exam and in making a determination on the employee’s injury/illness. If the employee is scheduled an appointment with a QME, the employee does not need to use his/her accruals (sick, vacation, CTO) if appointment is scheduled during working hours.

 If a claim is delayed, Sedgwick CMS has up to 90 days from the date of the claim to accept or deny a claim. The employee will receive written notification of the decision. Reports normally take 30-45 days after the QME.  If Sedgwick determines the claim is work related, the employee will be notified and the authorized medical

services will continue to be paid through our Workers’ Compensation Insurance. In addition used accruals (sick, vacation…) will be adjusted based on the Industrial Disability Leave Plan Fact Sheet. All Industrial

Disability Leave of absences must be certified by a treating physician. IDL payments are authorized by Sedgwick CMS. The employee must contact Sedgwick and Risk Management immediately if he/she has loss of time due to their work-related injury.

 When the doctor officially releases the employee to work, please provide a release to return to full-time work or modified duties to Risk Management. A medical release must be provided to Risk Management prior to

the employee returning to work. Please do not return to work without a medical release. Risk Management must discuss possible accommodations with the supervisor/manager PRIOR to an employee’s return to work.

 Doctor’s appointments, physical therapy, or additional treatment: Once an employee is returned to work but is still under the care of a physician, the CSU policy states--“If an employee loses work time for doctor’s appointments, physical therapy, medical procedures…such absences shall be charged to the employee’s leave credits”.

The information and Assistance unit of the Division of Workers’ Compensation is also available to answer

employees’ questions. Their telephone number is (800) 736-7401. The employee may also receive assistance by contacting: Sedgwick Claims Management Services, PO Box 14629 Lexington, KY 40512-4629

Telephone: (916) 851-8000 Fax: (916) 851-8089

Labor laws provide protections against retaliation for filing a workers’ compensation claim. Claim information will be handled in a confidential manner.

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Workers’ Compensation Benefits

There are 3 temporary disability benefits available under Workers’ Compensation. Each benefit is designed to provide you with wage loss assistance, in the event that your doctor releases you from work due to your work-related injury or illness. You may also receive a temporary disability benefit if your doctor places you on restricted duty, due to your work-related injury or illness, and the University does not have temporary transitional work available for you at that time.

 Industrial Disability Leave (IDL)

 Enhanced Industrial Disability Leave (EIDL) [Employees in Unit 8]  Temporary Disability Leave (TD).

Normally, there is a three (3) calendar day waiting period prior to the start of temporary disability benefits. This waiting period is waived if you are hospitalized as an in-patient, injured in a criminal act of violence, or disabled more than 14 calendar days.

Unless otherwise noted below, temporary disability benefits normally continue until one of the following events occur:

 Your doctor releases you to return to your usual job (whether or not you actually return to work).  Your return to temporary transitional work, permanent modified work, or permanent alternative

work with your doctor’s approval.

 Your doctor determines that your medical condition is permanent and stationary or that you are permanently unable to work.

Risk Management and/or Sedgwick will notify you if you are eligible to receive temporary disability benefits. Although you may be eligible to receive more than one type of temporary disability benefit, you may only receive one type of temporary disability benefit at a time. You must notify Risk Management of your benefit selection within 15 days of the date that you are notified of your eligibility to receive temporary disability benefits. The Industrial Disability Plan Fact Sheet form must be submitted to Risk Managment with your benefit selection.

If you are eligible for IDL benefits (or EIDL benefits for unit 8 employees) and you do not notify Risk

Management of your temporary disability benefit selection within 15 days, you will be automatically placed on IDL without supplementation (or EIDL for unit 8 employees).

Industrial Disability Leave (IDL)

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EIDL benefit does not apply to presumptive, stress-related disabilities, any psychiatric disabilities, or any physical disability arising from a psychiatric injury.

EIDL Pays you your full net pay for up to 1 year of disability, as long as your absences occur within 1 year of your date of injury. While you are paid EIDL, your normal CalPERS retirement contributions and voluntary deductions such as health, dental, and vision plans continue. You continue to accrue sick leave and vacation credits. EIDL is paid to you monthly by the University.

Temporary Disability Leave (TDL)

Anyone who is eligible to receive a temporary disability benefit may elect to receive TD. The amount that TD pays you is based upon California law and is determined by the date of your injury. The rate is normally 2/3 your average weekly wage with a minimum of $151.57 per week (or your actual weekly wage if that is less than $151.57) and a maximum of $1,010.50 per week for injuries or illnesses that occur on or after January 1, 2003. Sedgwick pays TD to you every 2 weeks. You continue to accrue sick leave and vacation credits. No

retirement contributions or voluntary deductions occur. You may elect to continue your health, dental, and/or vision plans by directly paying for them yourself. For more information regarding direct pay, contact the Risk Management Department at (510) 885-4227.

IDL Supplementation

If you receive IDL at the 2/3 gross-pay rate, you may supplement your IDL payments with your sick leave credits, in order to receive your full net pay. To supplement IDL payments, you must have sufficient sick leave credits to increase your payment to an amount equal to your regular daily salary or wage. IDL supplementation is generally limited to the use of sick leave credits that you accrued as of the date of your injury or illness or as of the first date of your IDL leave. IDL supplementation payments are taxable. You must notify Risk

Management, of your desire to receive IDL supplementation, within 15 calendar days of the mailing of the notice your temporary disability benefits eligibility by Sedgwick. IDL supplementation is paid to you monthly by the University.

TD Supplementation

If you receive TD, you may supplement your TD payments with your sick and/or vacation leave credits to increase your TD payments. You may increase your TD payments up to any amount equal or less than your full net pay. TD supplementation is generally limited to the use of sick and/or vacation leave credits that you accrued as of the date of your injury or illness or as of the first date of your TD leave.

If you supplement your TD payments, your retirement contributions will continue. If your TD supplementation amount is sufficient, your voluntary deductions including health, dental, and vision plans will continue. TD supplementation payments are taxable. TD supplementation is paid to you monthly by the University. Additional Workers’ Compensation Information

The Information and Assistance Unit of the Division of Workers’ Compensation is also available to answer your questions. Their telephone number is (800) 736-7401.

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Return-to-Work

Transitional Work/Reasonable Accommodations

Risk Management will periodically forward the supervisor/manager updates regarding the status of the employee. Often an employee may be recovered enough to come to work and perform transitional duties before he/she is able to perform the job fully. The

supervisor/manager will be notified once the employee is being released to full duty or modified duties. The supervisor/manager will be notified of such restrictions, if any. Work restrictions should be specific, such as no lifting over 25 lbs. or no standing more

than ten minutes at a time. Risk Management will discuss the work restrictions with the supervisor and employee to avoid any misunderstandings and to assist in determining if the restrictions can best be accommodated. Usually, simple ways of modifying a job can be identified by the supervisor/manager, the employee, and the Workers’ Compensation Coordinator.

Transitional work can be:

 Modified Work – Changing, transferring, or eliminating specific job duties within the employee’s regular job to meet the temporary work restrictions;

 Alternative Work – Offering the employee a position other than his/her regular job to meet the temporary work restrictions;

 Reduced-Hours Work – Offering less than full-time work to meet the temporary work restrictions.

Return-to-Work Process

The success of the Return-to-Work Program relies on the collaborative efforts between the employee and the supervisor/manager. Both parties need to be a part of this process to ensure success. The goal is to facilitate the transition from light or limited duty to the resumption of the employee’s regular job duties. California State University, East Bay’s Return-to-Work Program allows an employee with temporary work restrictions to work in a transitional position, for a defined period of time (up to 90 days), while recuperating from an injury or illness. If restrictions extend beyond 90 days, the Workers’ Compensation Coordinator and supervisor will need to re-evaluate the status of the employee.

The following is the typical Return-to-Work Work process:

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hours work. As needed the University’s Disability Compliance Officer will participate in process.

 Supervisor completes Return-to-Work Activity Analysis form outlining assigned duties based on dialogue with Workers’ Compensation Coordinator, employee, and if applicable--Disability Compliance Officer. Send completed form to Workers’ Compensation Coordinator for review.

 Workers’ Compensation Coordinator and Supervisor determine start and end date of

Return-to-Work Agreement based on physician’s note. Period not to exceed 90 days.

 Supervisor reviews Return-to-Work Agreement and Return-to-Work Activity Analysis with

employee. Supervisor and employee completes and signs Return-to-work Agreement.  Supervisor reviews Employee Information Sheet with employee and gives a copy to

employee.

 Copy of Return-to-Work Agreement and Return-to-Work Activity Analysis to employee

and forward originals to Risk Management.

 Workers’ Compensation Coordinator will contact department to generate an e-SAF/e-FAF reinstating employee from leave of absence.

 Employee starts transitional work as agreed upon.

 Once employee is returned to work but is still under the care of a physician, the CSU policy states that absences shall be charged to the employee’s leave credits (i.e., sick leave, vacation, CTO…) for doctor’s appointments, physical therapy, and/or medical procedures. The only exception is for attending a Qualified Medical Examination (QME) authorized by Sedgwick CMS. Please contact the Workers’ Compensation Coordinator for confirmation of date if employee requests time off for attending a QME.

 Workers’ Compensation Coordinator will provide updates on restrictions to supervisor as physician’s work status are received. Re-evaluate to-Work Agreement and

Return-to-Work Activity Analysis as needed. An amendment to these documents may be required.

 Supervisor monitors employee’s work progress.

 Supervisor reviews the progress of the Return-to-Work Agreement and Return-to-Work

Activity Analysis with employee at an agreed upon date (e.g., midpoint).

 Supervisor contacts Workers’ Compensation Coordinator near conclusion of the

Return-to-Work Agreement to discuss whether the plan should be terminated, extended, or altered.

 Supervisor meets with employee to inform him/her of terminated, extended, or altered agreement. An amended Return-to-Work Agreement and Return-to-Work Activity

Analysis may be required.

Supervisor shouldcontact the Workers’ Compensation Coordinator in Risk Management (510-885-4227) for assistance during any part of this process.

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Monitoring the Return-to-Work Program

Modified and alternative jobs are temporary in duration, and subject to regular re-evaluation. The treating physician will address any restrictions if applicable, upon each medical appointment. Upon receiving additional information, the University will re-evaluate its ability to provide temporary, modified work and to increase or decrease the assigned tasks, based on the restrictions outlined by the physician.

Roles/Responsibilities Employee:

 The employee is responsible for providing Risk Management with a work status form from his/her doctor indicating the physical restrictions and the expected duration prior to returning to work.  If a medically appropriate transitional assignment has been found, the employee must accept the

assignment; otherwise, he/she jeopardizes his/her temporary disability benefits if the assignment offered is turned down without good cause.

 Work within the limits of the Return-to-Work Activity Analysis and physician’s medical release. Department:

 The department is responsible for working with Workers’ Compensation Coordinator in providing a transitional assignment within the department upon receipt of the employee’s medical restrictions.  If no transitional work is available, the department is responsible for documenting why an

assignment is not possible.

 Ensure that employee released to modified work is working within the job restrictions.

 Ensure that employee receives a thorough return to work orientation and that they understand the University’s return to work guidelines.

 Report any absences related to the work injury to the Workers’ Compensation Coordinator. Workers’ Compensation Coordinator

 Establish clear, consistent return to work guidelines.

 Monitor medical progress of the eligible employee and initiate the Return-to-Work Program.  Ensure an understanding of the program by both the supervisor and the affected employee.  Verify that all participants understand the work limitations and abide by the plan guidelines.  Monitor the program plan.

 Meet with the supervisor/manager and the employee as needed. Permanent Restrictions/Reasonable Accommodations

In the event an employee’s physical/mental restrictions become permanent and the employee is not a Qualified Injured Worker (QIW), which would be a vocational rehabilitation issue for injuries prior to January 1, 2004, and are handled through Workers’ Compensation, the Department in conjunction with Risk

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Forms and Related Information

Forms can be downloaded from the Risk Management’ website:

www.aba.csueastbay.edu/?

 Disability Payment/Deductions Summary

 Employee’s Injury/Illness Report

 Employee’s Job Duties (DWC RU-91)

 Instructions for Completing Employee’s Job Duties (DWC RU-91)

 Industrial Disability Fact Sheet

 Personal Physician Designation

 Work Activity Analysis

 Work Activity Analysis (Sample)

 Return-to-Work Agreement

 Return-to-Work Employee Information Sheet

 Supervisor's Injury and Illness Incident Report

 Workers' Compensation Benefits

 Workers' Compensation FAQs

 WC Posting (English)

 WC Posting (Spanish)